Joint manipulation

1. The Evidence up to 2004
• Assendelft et al. Cochrane Database Syst Rev. 2004
• Systematic Review of RCT’s that evaluated spinal
manipulative therapy for patients with low back pain
were researched to update effectiveness of spinal
manipulation in comparison to other therapies

4. What are the side effects?
• Senstad et al (Spine, 1997) Surveyed 1058 patients treated with
spinal manipulation in Norway
• 75% of all treatments included manipulation to the Lx Spine
• No severe complications noted 55% reported at least one side effect
• Local discomfort-53%
• Headache-12%
• Fatigue-11%
• Radiating discomfort- 10% 40
• Symptoms resolved < 48 hours in 81%

5. Comparison Treatments
Classified in seven treatment categories:
•Sham
•Conventional general practitioner care
•Analgesics
•Physical Therapy
•Exercises
•Backschool
•Therapies judged to be ineffective or even harmful (traction,
corset, bedrest, homecare, topical gel, no treatment and diathermy)

6. Outcomes
Manipulation had no statistically or clinically significant
advantage over general practitioner care, analgesics, physical
therapy, exercises or back school
For patients with acute low back pain, manipulation was
superior only to sham therapy, or therapies judged to be
ineffective or even harmful

7. Clinical Prediction Rule for Spinal Manipulation
• In 2004 Childs et al developed a clinical prediction rule to identify
patients with low back pain most likely to benefit from spinal
manipulation ).
• Purpose: determine the likelihood of patients responding with a
50% or greater reduction in disability following a program of spinal
manipulation and exercise.
Childs, J. et. al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Annals of internal medicine
Vol. 141, No. 12, 2004

8. Five criteria were identified
• Duration of current episode less than 16 days
• No symptoms distal to the knee
• Lumbar spine hypomobility at any level
• FABQ work subscale score <19 points
• Hip internal rotation with 1 or both hips having at least 35
degrees of internal rotation

9. Outcome
• When at least 4 of the five criteria were met: +LR = 13.2.
• When only 1 or 2 of the criteria were met: - LR = .10

10. Which patients do not benefit from
spine manipulation?
• Longer symptom duration
• Presence of symptoms distal to the back
• Absence of hypomobility in the lumbar spine
• Negative SI provocation tests
• Reduced hip rotation ROM

11. Better outcomes with manipulation
• A case control study by Fritz showed that patients receiving
thrust manipulation had:
• Fewer treatment sessions,
• Shorter length of stay
• Lower cost in physical therapy than patients receiving non-
thrust manipulation.
Fritz JM, Brennan GP, Leaman H. Does the evidence for spinal manipulation translate into better outcomes in routine clinical care for patients with occupational low back pain? A case control
study. Spine Journal 2006

12. So why the reluctance to manipulate in the
face of overwhelming evidence?
Two main reasons:
• Not educated well enough
• Fear of harm

13. Complications
Serious complications due to L spine manipulations are
extremely rare. It is estimated at 1 per 100 million lumbar
manipulations results in a cauda equina lesion
In comparison, each year 7600 people die in the US alone as a
result of taking NSAIDs
Another 76000 people require hospitalization as a result of
taking NSAIDs

14. Safety and effectiveness
Not dependent on:
•Type of practioner
•Technique used
•Years of experience

15. Cervical Spine CPR
•Symptom duration < 38 days
•Expectation that manipulation will help
•Difference in C rotation side to side >10 degrees
•Pain with PA spring testing mid C spine
If 3 out of 4 attributes present, the probability of
experiencing a positive outcome improved to 90%
Positive LR 13.5
•Puentedura E et al. Development of a clinical prediction rule to identify paitients with neck pain likely
to benefit from thrust joint manipulation to the cervical spine. JOSPT 2012 Vol 42 No 7

16. CPR for treatment of a subgroup of patients with neck
pain with T spine manipulation, exercise and education
Cleland et al. Physical Therapy 2007
Six predictors were developed
•Symptom duration < 30 days
•No symptoms distal to the shoulder
•Looking up does not aggravate the symptoms
•FABQPA <12
•Decreased upper thoracic kyphosis
•Cervical extension <30 days
If 3 of 6 present: 86% success rate with manipulation

17. The audible pop is the sound
resulting from the release of
nitrogen gas in the joint cavity
when a sufficiently large
negative pressure is created
The audible pop

18. Flynn (2006) concluded that a
perceived audible pop may not
relate to improved outcomes for
patients with non radicular low
back pain, either immediate or at
long term follow up
The audible pop

19. Beffa (2004) found that
manipulation was not associated
with the targeted joint frequently
enough to make a statistical
difference
Does spinal manipulation cavitate the
targeted joint?

20. KimRoss (2004) found that manipulations are accurate
about half the time
In the L spine the average error was at least one vertebra
away from the targeted level.
(5.29 cm)
In the T spine the average error was 3.5 cm
Most procedures were associated with multiple
cavitations, including the targeted level
Accuracy

21. Mechanical
Psychological
Neurological
Effects of Manipulation

22. Mechanical Effect of Manipulation
•Restore positional faults
•Breaking up intra articular
adhesions
•Release of meniscoid
inclusions

23. Positional Fault Talus

24. Stress reaction Talus

25. Mechanical force used during
manipulation has a direct effect on
the central nervous system, creating
positive neurophysiological responses
resulting in a reduced overall central
sensitization
Neurological Effect of Manipulation

26. The effects of manipulation are
beyond biomechanical changes
only; however, in the current
literature, there is no clear
explanation for some of the
effects of manipulation
Sillevis et al. Immediate effects of thoracic spine thrust manipulation JMMT 2010
Neurological Effect of Manipulation

27. Effect on autonomous nervous
system
Thoracic spine manipulation showed favorable outcomes in the
treatment of a patient with UE complex regional pain syndrome
T spine manipulation resulted in a decrease in dystrophic and
allodynic symptoms
Menck et al. Thoracic spine dysfunction in upper extremity complex regional pain syndrome
type I. JOSPT 2000;30(7)

28. Cervical Spine Manipulation for Pediatric Population

29. Anatomical Considerations

30. Biomechanical considerations

31. Biomechanical considerations

33. Informed Consent
You have to obtain informed consent
Verbal consent is recommended and document
as such in your notes
Informed consent differs from state to state,
which makes it difficult to specify how this
needs to be worded

34. Our recommendation
“I would like to perform a “quick stretch” to
your neck to improve the movement of a
particular joint. You may sense a “popping” of
the joint and may experience some local
soreness due to the stretching procedure. Is it
OK to perform this quick stretch?”

35. Component technique
•In component technique we aim to create the barrier
•Use basic principles of focusing, multiple components, and for
“locking” contra rotation
•Use secondary components to minimize amplitude of primary
component or lever
•Use compression
•Identify the barrier, then back of a little
•Hold the secondary components to maintain the barrier and
amplify only the primary lever direction
•Use good posture for security and effectiveness
•When ready, focus forces, and engage the barrier

36. Posture and Manipulation
Conscious considered use of operator posture helps control:
•Depth of forces
•Direction of technique
•Amplitude of levers
•Power of the procedure
•Sensitivity of hold
It improves the ability to focus the forces to a specific target site
It helps improve safety, security, effectiveness and reduces fatigue

37. Posture and Manipulation
General rules
•Use a wide base
•Use your body to perform technique, keep your hands “fixed”
•Use rhythm
•Demonstrate control

38. Posture and manipulation
•Keep your head up. Literally
•Keep your knees slightly bent
•Move with your hips, and have your hands follow
•Keep your centre of gravity low
•Visualize the procedure
•Keep the objective in mind
•Play with the tissues
•Mini thrusts

39. Keep your head up
•Keeps the spine straight
•The straighter the spine, the more force directed into the
patient, not the therapist
•Avoids too close proximity
•Brings elbows close to side for improved control

40. Keep knees slightly bent
•Sharper impact possible
•Less flexion in your spine
•Subtle changes in direction can be accommodated
•Less bending in the PT spine

41. Move your hips, with hands following
•Easier acceleration
•Hands are less uncomfortable for the patient when held steady
•Proprioceptive palpation with operator body
•Hands follow, allowing for maintenance of local control

42. Keep center of gravity low
•Better balance
•Easier changes in direction
•Better transmission of force
•Less therapist muscle stress

43. Visualize the procedure
•How is your posture?
•Are you using max efficiency?
•Do you understand the principle of the procedure?
•What would your posture look like in the mirror?

44. Keep the objective in mind
•Is another way better?
•Are you struggling with the wrong aspects?
•Is control of the structures a problem?
•Is another way possibly better?

45. Play with the tissues
•Constructive fiddling is often useful to find the optimal
direction/path of manipulation
•Keep it moving. If you hold it still you only have about a 2
second window to perform the technique
•Tissue reaction is the best guide, keep testing and assessing the
responses
•Less mistakes if you ask the tissues

46. Mini thrusts
•Prepare the tissues for final thrust
•If you use only one thrust, you have a 25% chance of a good
technique. Using mini thrusts significantly increases your
chances of a good technique
•Tissue anger will warn you off with mini thrusts
•Barriers often ease without a more major method
•Easier to get to the motion barrier with mini thrusts

47. In thrust techniques
• Usually one leg forward, one back
• The thrusting hand is on the side of the rear leg
• The rear heel is slightly raised
• Keep your back straight
• Brief isometric contraction of the abdomen

48. Focusing (isolate) to the segment
• Focus to the joint using one or more vectors of
compression, creating local tissue tension
• Build the barrier
• Once you have identified the barrier, back off a little
• Use posture for security and effectiveness
• When ready, focus your forces, and engage the barrier
• Hold the secondary components to maintain the
barrier and amplify only the primary lever direction

49. How can we focus without locking?
• Use several components
• Control the part being worked accurately
• Direct forces according to anatomical principles
• Be highly aware of palpatory cues
• Learn how tissues respond to varied forces
• Keep an open mind to the varied possibilities

50. Basic routine to build barrier using
multiple components
• Focus to the segment
• Test the primary lever amplitude at the segment
• Add some of the 1st chosen secondary lever
• Retest the primary lever:
• If the endfeel is not good, add some of the 2nd chosen
secondary lever
• Retest the primary lever
• If the endfeel is still not good:
• Add some of the 3rd chosen secondary lever
• Retest the primary lever amplitude
• At optimum barrier point, thrust in primary lever - without
losing the other components